Sunday, July 17, 2011


I am a practicing physician, a medical research scientist, and a medical school teacher and many of my close relatives are physicians and medical scientists as well. But anyone who thinks it is easy for me and my family to make decisions about how various medical conditions should be approached and treated for ourselves and our loved ones would be mistaken. These are very tough issues. Many decisions are tough because there is a lack of settled opinion. Recently I read an online blog which pointed a finger at misleading advertisements by pharmaceutical companies ( I answered the blog in a comment which I am repeating here.

Misleading advertisements may play a role but I do not believe they are the only factors to be considered. I have found that the availability of medical information via the internet is a two edged sword. One can find information much faster than ever before. But even for a physician judging the quality, validity, and context of medical information is difficult. As with most other products, one must be skeptical of advertisements for medications. It is also important to be on the alert for information provided by those with hidden agendas regardless of whether they are commercial firms, government entities, or other interested parties. I do not think there is any perfect answer.

The column at mentioned some reasonable point but I would urge readers to be skeptical about some of its recommendations as well.

1) The advice, from a Dr. Harold Bursztajn (whom I know and who is a very intelligent and thoughtful person) said the following: “What ‘adjunct’ means — Beware of recommendations that focus on FDA approval of a medication as an “adjunct” treatment without mentioning that this means that it’s not a first-line treatment for the condition in question.” I think it is misleading to tell people to “beware” of such recommendations. Though it is never wrong to know the precise “indication” for which a drug has been approved, this should not be interpreted as meaning that it is wrong to use the medication for other purposes. What is the best drug under a given circumstance is often debatable, but knowledge of indications for various drugs under various circumstances is an important part of the ever changing knowledge that physicians learn in medical school, residency and continuing education. In neurology, which I practice, it is often indicated, necessary, and demanded by the generally accepted standard of care to use the so-called “adjunct” medicines as first line and often “stand alone” medications. It is also often very valuable to use medications that have been approved for completely different purposes and were not even approved as an “adjunct” for that purpose (though it would be illegal for the company to advertise the drug for that purpose).

Depending on the spectrum of one’s patients, many good doctors prescribe “off label” at least 50% of the time. In the cases that I typically see, I prescribe “off label” about 25% of the time and I would be subjecting my patients to harm if I did otherwise. There are numerous reasons for this. The usual reason is that after a drug is approved for one usage, subsequent clinical research shows that it is as useful or even more useful for something else. But unless a drug company (or some other entity) is able to spend a large amount of money getting an additional approval, the formal FDA approvals for the other usages is never obtained. This is an accepted practice. Most medications with which I am familiar have many, many important uses aside from the FDA indications. Both neurology and psychiatry are fields in which “off label” uses, either using the “adjunct” drug as a first line treatment or using a medication for a completely different purpose than the one for which it was approved, is very common and, in my opinion, often very necessary.

2) The Commnhealth column says that patients should be aware that “indicated” does not mean “necessary.” It is true that “indicated” and “necessary” are not precise synonyms, but I doubt that making such a distinction is very helpful and it could be confusing. There are really many slightly different definitions of both of these words. “Necessary” is often used by insurance companies and other payers, especially when they reject payment (i.e. “the treatment was not necessary and, therefore, it is not covered”). Probably more important than the idea that indicated and necessary do not mean the same in thing is the caution that a treatment deemed “not necessary” or even “unnecessary” (by an insurance company, Medicare, an advice columnist or even your own doctor) does not always mean that the treatment is really not necessary to save your life or preserve your health. In my experience, I have seen a large number of patients who have been severely harmed by being told that a treatment was not necessary. But I cannot say, and I doubt that anyone can honestly be sure, whether more patients are harmed one way or the other. Some are harmed both ways, they fail to get treatments that would really do them a lot of good and they receive treatments that harm them. Blindly following FDA guideline (or blindly following any guidelines) tends to lead to such problems

3) Googling lawsuits and side effects of a drug was recommended. This could well give you some important information and I would never tell you not to do it. But doing so usually turns up isolated, random tidbits that are sort of like the “sound bites” in a political campaign. It is very hard to figure out the overall context. If you have a disease or other medical condition (e.g. traumatic brain injury) there are some other sources that I would recommend much more highly than googling for side effects of the drugs you were recommended. You really need to start with more comprehensive, connected accounts of the type that used to be found in (of all things) books (remember those?). Here are some modern alternatives.

a) This one may surprise you because it is so old fashioned. Subscribe to Consumer Reports. They actually have a separate online subscription for health articles (many of which are not included with the regular subscription). Despite my access to two medical school libraries, numerous personal medical journal subscriptions, and personal ownership of over $15 thousand dollars worth of medical textbooks (which at today’s prices is not all that many books), I actually subscribe both to the regular and health Consumer Reports and I often read their articles on medically related topics when something comes up in my own family. I’m not too proud to think that a “consumer” publication can teach me something. They have no advertising and though no one in the world is completely unbiased I think their articles are about as unbiased as you can get.

b) Online medical textbooks are available. The cheapest of these is EMedicine, which is now called Medscape Reference. You can still get to it via This IS supported mainly by advertising. But medical school libraries also pay to subscribe. It is peer reviewed. I have written and edited articles for it myself (and I have been paid three or four hundred dollars a year for the past few years doing so). I think its articles are of quite good quality, comparable to what one may find in a very expensive medical textbook. You probably can get to the advertising free version if you were to go to the closest medical school library and ask the librarian if you could look something up on one of the library’s computers (though I cannot guarantee that you would be given access). Public libraries may also have this version. But the text of the articles is exactly the same in both. So unless you are a super purist I do not see the advantage of the advertising-free paid version. Medical school and some public libraries also have many other medical texts. There is another online textbook called “Up to Date.” You can use the patient’s version free online. If you want the professional version it will cost you $44.95 per month. Physicians and other health professionals can subscribe for $495 a year (I bet they would let non-physicians get a year’s subscription as well but probably the idea is that an individual patient would need it only for a short time every now and then).

c) A handy and relatively inexpensive, yet comprehensive, medical textbook is the Merck Manual. There is both a patient’s version and a professional version. One need not be a physician to buy the professional version. They also have a website though I believe one must be a physician to get the online physician’s version.

d) You might also want to look at my page on finding medical information at a different part of this website:

My best general advice would be to start by reading whatever you can find about a given medication or category of medication in consumer reports. Then consider other sources such as EMedicine, the Merck manual, and websites of professional organizations and medical schools. If necessary, spend a few hundred dollars (if you can) and purchase a "real" medical textbook on the subject of interest. These days, many such books also include access to a more comprehensive website.

Following these suggestions will cost you anywhere from nothing (for EMedicine) to several hundred dollars if you end up buying some resources (Consumers Heatlh is about $20 per year). But though this may cost you a little, you will get a better understanding of the overall context of the treatments than you will obtain by wading through thousands of disconnected “sound byte” quality articles dredged up by Googling.

Monday, February 15, 2010

Book Reading at NYAM: SUPERHEROES & SUPEREGOS by Sharon Packer, MD

NYAM Author Night Series: Superheroes and Superegos Analyzing the Minds Behind the Masks
Location: The New York Academy of Medicine, 1216 Fifth Avenue at 103rd Street, New York, NY 10029
Speakers: Sharon Packer, MD

This comprehensive collection of essays written by a practicing psychiatrist shows that superheroes are more about superegos than about bodies and brawn, even though they contain subversive sexual subtexts that paved the path for major social shifts of the late 20th century.

Psychiatrist and social advocate Fredric Wertham lobbied against comics because of their sexual and sadistic subtext and their potential to reverse women’s roles and encourage same-sex behavior. However, Wertham’s McCarthy Era stance forgot that early superhero comics foretold Hitler’s threat—and offered solutions.
Superheroes have provided entertainment for generations, but there is much more to these fictional characters than what first meets the eye. Superheros and Superegos: Analyzing the Minds Behind the Masks begins its exploration in 1938 with the creation of Superman and continues to the present, with a nod to the forerunners of superhero stories in the Bible and Greek, Roman, Norse, and Hindu myth. The first book about superheroes written by a psychiatrist in over 50 years, it invokes biological psychiatry to discuss such concepts as "body dysmorphic disorder," as well as Jungian concepts of the shadow self that explain the appeal of the masked hero and the secret identity.
Readers will discover that the earliest superheroes represent fantasies about stopping Hitler, while more sophisticated and socially-oriented publishers used superheroes to encourage American participation in World War II. The book also explores themes such as how the feminist movement and the dramatic shift in women's roles and rights were predicted by Wonder Woman and Sheena nearly 30 years before the dawn of the feminist era.
Looks at cultural psychology as much as individual psychology to analyze the political backdrop of superhero stories
Explores the importance of the secret self, the shadow self, and myths of metamorphosis, and shows how superheroes function as wounded warriors in contemporary society
Shows how the teenage creation of Superman of 1938 was prophetic and speculates whether the rise in superhero cinema in the 21st century may be equally prophetic of political catastrophes to come


Schedule of Events:
Registration: 5:30 — 6:00 PM
Program: 6:00 — 7:00 PM
Registration Options:
This event is free but pre-registration is required
Copies will be available for purchase.
Sharon Packer, MD, is a practicing psychiatrist and assistant clinical professor of psychiatry and behavioral science at Albert Einstein College of Medicine of Yeshiva University, Bronx, NY. Her published works include Dreams in Myth, Medicine, and Movies and Movies and the Modern Psyche.

Registration Options:
General Admission / Free

Wednesday, September 16, 2009

My First Posting to Sigmund Freud's Couch

As I mention in my introductory comments, I chose the Freudian theme because of the breadth of the neuropsychiatric arena. As an example of how expansive the world of neuropsychiatry is, I refer the reader to another blog "Mind Over Movies" written by psychiatrist and author Dr. Sharon Packer. Her outstanding new blog gives a neuropsychiatric slant to the appreciation of the movies.

You can find it at

Welcome to Sigmund Freud's Couch

Though Sigmund Freud is today best known as a psychiatrist and the founder of psychoanalysis, his core medical training was in neurology. As a neurologist he wrote a key monograph on aphasia, i.e. acquired neurologically based language dysfunction. He also wrote one of the earliest known scientific studies on the effects of cocaine.This blog is not designed to recount Freud's life, however. I chose the name and the Freudian theme because I want to blog across the boundaries of psychiatry and neurology. In my view, this gives me leeway to blog about most anything.